Tensions and barriers in improving maternity care: The story of a birth centre by Ruth Deery, Deborah Hughes and Mavis Kirkham

Sheila Kitzinger begins her foreword to this publication by saying: 'Here is a remarkably detailed analysis of the politics of a birth centre trapped in a medicalised system that threatened and rapidly destroyed it. It is a vivid example of how autonomous midwifery is undermined by an organisational structure in which management focuses exclusively on one model of care, namely midwifery training in obstetric emergencies and rescuing women from their inherently defective bodies, rather than safeguarding normal birth.'

The three exemplary midwife authors of this must be read book have carefully and painstakingly sought and listened to the stories of those involved with the development, opening, running, management and closing of the birth centre, whose five-year history they followed. As the authors point out, and as we well know, birth centres, like home births, provide excellent care that can improve outcomes for women and babies (especially those experiencing disadvantages in our society), and are much preferred by families and midwives.

The sad tale told in this book provides a salutary and detailed lesson about how not to go about introducing potential improvements to maternity services. From the midwife who carried out the initial feasibility study, to the midwifery managers, the midwives running the service, and those somewhat removed from the whole fiasco, the quotations show that the birth centre was set up to fail from the moment it was first conceived. The many, fascinating, frank, passionate and often sad quotations show how the potential, the optimism and skills invested in the birth centre were gradually, but consistently, undermined every step of the way through lack of leader ship, lack of confidence in birth and midwifery, lack of a shared vision and philosophy, lack of support from GPs, obstetricians and even midwifery managers, and finally by restricting opening hours of the centre and 'integrating' it so that it no longer had its own dedicated midwifery staff.

The quotations also show that the impact on individual midwives who came to the centre to their 'dream job' was extremely costly as they fought to retain some degree of autonomy, fought to keep the centre open and fought to provide the woman-focused care that was needed by the community. The stress, pain and powerlessness experienced by some of the midwives who wanted to provide the kind of care that we are told by Government needs to be provided, that we know has positive impacts on communities and that we know women want are of huge concern: they are driving away the very midwives who are most committed to providing the holistic midwifery care that most benefits families, and driving down excellence in maternity services. As the author s suggest: 'It is difficult for midwives to facilitate safety and empowerment for women if they are feeling threatened and undermined in their work setting.' (p103).

One of the problems within midwifery (and how we are generally pitted against each other in financially driven organisations) is well described by the authors: 'The "corporatisation" of professional managers that was evident here is often difficult for front-line staff to accept, as it represents a schism in previously shared professional values and commonality of outlook and priorities. These managers may continue to have the words "midwife" or "midwifery" in their job titles, but they are expected to dampen down or constrain the aspirations and demands of their fellow midwives arising from the core values of midwifery, so that they comply with corporate strategy and financial budgets' (p49). This schism is played out in the differences between bir th centres and obstetric units where beliefs, values and practices are markedly different, and where midwifery and woman-focused care flourishes in the former but not the latter. Put simply, everything about a birth centre potentially supports women, birth physiology and midwives, whereas everything about a large obstetric institution potentially undermines women, birth physiology and midwives.

Another problem for birth centres is the context in which they are often planned. When services are centralised and maternity units closed, ensuing public outcry is unlikely to be appeased by the suggestion of a birth centre. This is seen as a reduction in services rather than an improvement. For birth centres to be a well-used, effective and stable part of maternity services, they need to be carefully planned in the context of overall services, so that we can achieve AIMS' goal of many more small, stand-alone birth centres supported by obstetric units that would be smaller than they are currently. These units would provide care for the minority of women who need technological and medical care as well as providing backup suppor t for women and babies birthing in the community.

The authors list the potential benefits of birth centres:

choice

location of birth within a community or geographical area

homebirth-like facilities for women who are homeless or who have poor housing

inclusion and welcoming of partners and families into the birth environment

a place of safety and retreat from daily life

a community hub

a valuing of social outcomes for maternity care

(p100)

Finally beware the 'changes in language of policy that repackage previously negative concepts as positive. "Reconfiguration" is a modern packaging of what were previously termed "cuts and closures". A shortage of, or reduction in, professional clinical staff is repackaged as "skill mix". Cuts in the number of antenatal and postnatal visits to women at home have been described as "individualised care", although midwives find it difficult to increase care for needy women. Similarly, "protocol-based care" is positively packaged as evidence based and managing risk, but may not respond to the needs and wishes of individual women.'

If you want to improve maternity services, easily understand the politics of maternity care, set up birth centres in your area, protect existing ones, or fight the closure of one, this book will be an enormous help to you. It's a brilliant read too.

Preparing for a healthy birth by Sylvie Donna

Sylvie Donna became aware of birth stories when pregnant with her own children. More and more, she heard tales of traumatic, difficult birth experiences and discovered that the impact of a 'bad' birth was felt for a long time, not only by the woman her self but by the rest of her family too. The disempowerment and betrayal felt by these mothers was strong enough to impel her to write this book.

When I first opened the book, I dived straight into the middle of it. I quickly found the style to be very assertive and I could feel my barriers come up. Thankfully, I managed to override this and continue reading. The book is set out in steps rather than chapters, with plenty of anecdotal stories to illustrate points.

While it is, indeed, very prescriptive (What is a healthy birth? Step 1 - Understand Healthy) it is also incredibly informative and full of very good ideas. My favourite one is the underlying theme of letting nature take its course, while maintaining good health in yourself. i.e. don't mess with the process - it's very finely tuned!

The author puts forward the concept that you need to accept you have no real control over the process and each step takes you through aspects you may not have considered. For example, in Step 7 - Choose Who, she mentions the idea that the relationship between the mother and partner may be negatively affected by being present at the birth. The long-reaching implications of this change within the relationship is, in my opinion, severely under-addressed.

There are so many suggestions - ways in which the labouring woman can deal with variations from the 'norm' for example, 'What if you're told your baby's posterior', breastfeeding advice, healthy diet, what to put in your bags, what the baby will need - this book is more than just about the birth. It is an incredibly full antenatal class in one volume.

If you read this book with an open mind, there is still no promise or guarantee you will end up with the 'ideal' birth, whatever that may be, but you'll have gone a fair distance to becoming empowered and doing your best in preparing for a healthy birth.